Review: Research Report on Pain and Depression in Older People

The paper reviewed here is ‘Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking’ by Bonnewyn and colleagues. In the conclusion to the abstract the authors write that

‘(Painful physical symptoms) were more likely in people with a 12-month major depressive episode (MDE) than in those without (OR=2.0)‘

In the introduction, the authors cite research showing a prevalence of pain in older adults of between 25 and 88%. The authors then briefly discuss the pain-depression dyad explaining the antecedent and consequence hypotheses which expand on the nature of the dyad. The aims of the study are clearly outlined and include an evaluation of the relationship between pain and depression in a community-dwelling sample of older adults (65 years and older) as well as the interactions with the use of mental health services and benzodiazepine use.

The data was obtained from the European Study on the Epidemiology of Mental Disorders (ESEMeD) a study which was initiated by the World Health Organisation. Data was obtained from 6 countries – France, Germany, Italy, Belgium, Holland and Spain. The researchers write that some of the specifics of the sampling process have been described in another paper. I wasn’t clear on the details of the sampling method as a result and the researchers note that

‘a stratified, multistage, clustered area, probability sample was used‘

59.4% of the sample were female and 38.4% were age 75 and over. 36.3% of the sample lived in rural areas compared to 26.6% that lived in urban areas. The majority of the sample (52%) had 0-11 years of education. Participants were interviewed using the Composite International Diagnostic Interview with major depressive disorder diagnosed using DSM-IV criteria and a list of questions used to detect the presence of painful symptoms specifying within the last 12 months in some of these questions. They were also asked if they had one of a number of chronic medical conditions some of which are common medical conditiosn (e.g. asthma and diabetes). They were also asked about antidepressant and benzodiazepine use. Their estimated point prevalence of painful physical symptoms in the sample was 31.8% and although they were calculated as more common in men there was no confidence intervals for this comparison. PPS were significantly more likely in females with major depressive episode than those without. Using depression as the dependent variable, the researchers ran a multvariate analysis which identified female gender and pain as predictors of depression. Without major depression, the likelihood of antidepressant use was three times greater in those with painful physical symptoms compared to those without. For participants with depression, there was no significant difference between those with and without painful physical symptoms in the use of antidepressant medication. There was a doubling in the use of benzodiazepines in those without major depression but with painful physical symptoms (PPS) compared to those with major depression but without PPS. Major depression was also found to be signficantly associated with benzodiazepine use.

In the discussion, the authors note that from their results somatic conditions mediated the relationship between depression and pain. The authors also  comment on the two-fold increase in PPS with major depressive episode and the increased prevalence of PPS with female gender. Whilst these latter two findings were consistent with previous literature, like the researchers I found the results for antidepressant and benzodiazepine use interesting. Firstly antidepressant use was found to be higher in those without major depression but with pain. The use of benzodiazepines was increased in those with major depression also. I wasn’t clear if there was a prominent anxiety component in those using benzodiazepines but given that only 20% of those with depression were receiving antidepressants a different pattern of prescribing could be explored. This however would depend on local guidelines particularly as the sample is taken from 6 countries.

In conclusion, I thought there were some interesting findings here particularly the use of antidepressants in those with pain but not major depression. It could be that the depression had been previously treated and was in remission. Alternatively it could mean that the subject or the prescriber had intended for the antidepressants to be used for the pain. It would be interesting to see how factors such as pain duration and intensity impact on antidepressant use. The paper provides valuable insights into the relationship between pain and depression in older adults and I would be interested to see in particular if there are any follow-up studies examining the use or underprescribing of antidepressants as well as benzodiazepine in the same or other regions.

References

Bonnewyn A, Katona C, Bruffaerts R, Haro J M, de Graaf R, Alonso J and Demyttenaere K. Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking. Journal of Affective Disorders. 117. 193-196. 2009.

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Review: Literature and Happiness

The article reviewed here is ‘Literature and Happiness’ by Norman Holland and published in the journal Psyart in 2007. Psyart publishes articles which examine psychological perspectives on the arts. In the abstract (headnote), Holland writes that

‘I maintain that we do literature because it is fun, because it makes us happy. And it makes us happy because the act of experiencing literature mimcs the brain processes of successful living‘

I was intrigued to read a little more to see what Holland meant by this. He begins by looking at the origins of the word happiness and an overlap with terms such as luck in indoeuropean languages. He then describes a modern meaning in which the pursuit of happiness is validated in a western society. Indeed this features in the positive psychology movement (see review here). He writes about reading for pleasure and as a literary critic and then discusses psychologist Mihalyi Csikszentmihalyi’s description of happiness in flow – equivalent to absorption in a task. He then equates the first type of reading – the reading for pleasure with the activation of a wanting and liking system – the neurological correlates of which are the mesocortical and mesolimbic systems. He refers to a Seeking model described elsewhere with regards to the wanting and liking systems. This is where he draws the analogy with ’successful living’ as he suggests that the cycle of wanting and liking are routine and exclusive drivers of our behaviours. With regards to literary criticism he relates this to activity within the peri-aqueductal grey matter (PAG). The connection he makes is with a theory of ‘personal style’ described elsewhere in which the PAG plays a prominent role.

In terms of other articles reviewed previously this has a different tone far removed from papers describing studies with quantitative and qualitative methodologies. The article is essentially an essay in which a structured hypothesis is described. There are various methodologies that could be used to explore this model in further detail ranging from focus groups through to surveys and imaging studies. Nevertheless this ‘top-level’ informal-at-times discussion is just as valid as rigorous qualitative or quantitative studies in that it disseminates a speculative model which can lead to further discussion. There are many reasons for reading and many functions that it may satisfy as well as numerous brain regions or systems that may be involved in the process quite apart from the PAG, mesolimbic and mesocortical systems although each should start with a suitable evidence to justify their inclusion in the model. Is my peri-aqueductal grey matter helping ‘me’ to write this review? I’m not entirely sure, but until I’d read this paper I wouldn’t have entered my stream of consciousness. There at least it has already had some success.

References

Holland N. Literature and Happiness. Psyart. Gainesville. 2007. I page. ISSN: 10885870.

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